MLCPTM Health Care Document Set / Data Entry
AUDIO INTRODUCTION
Entry fields with a red asterisk (*) are minimally required for submission.
*Access Code:
1) CREATOR / SPOUSE PERSONAL INFORMATION
Creator:
  M
Yes No
*First Name MI *Last Name
DOB F
      U.S. Citizen
Spouse:
  M
Yes No
First Name MI Last Name
DOB F
      U.S. Citizen
Address:
*Street Address (or P.O. Box No.) Unit
*City
*County/Parish *State
*Zip Code
Contact:
*Daytime Phone Other Phone
*E-mail Address
2) PERSONAL HEALTH CARE AGENT APPOINTEES
If you are married, it is assumed that your spouse will serve as your Primary Health Care Agent, if able, before the appointees listed below.
Client's Appointments:
1) /
First Name Initial Last Name Relationship
2) /
First Name Initial Last Name Relationship
Spouse's Appointments:
1) /
First Name Initial Last Name Relationship
2) /
First Name Initial Last Name Relationship
NOTES / COMMENTS / QUESTIONS

NOTICE TO PURCHASER:  Entries in the "Notes/Comments/Questions" textbox below will be auto-posted and permanently recorded in your (forthcoming) Client Console's NotePad Message Center.  Archived NotePad message entries can be made available, by your choosing, for viewing and additional text entry applications by your legal counsel and/or other select persons.

Make Your Health Care Document Set Order Here

Notice: Access Code entry is required (top of page)
in order to view Contract & Purchase Agreement

I/(We), the person(s) identified above as the Client (& Spouse) for the purposes of this transaction, now elect to purchase the My LifeCard Plan (MLCP) Health Care Document Set for the amount of the Placement and Membership Fees as defined in the Contract & Purchase Agreement linked hereunder.  NOTE > You must click on the button below to view the Contract and Purchase Agreement and then the "I AGREE" button at the bottom of the Contract page:


Credit Card/ Debit Card   (or)  TRY BEFORE YOU BUY
          Bank Card No. Card Verification No. Exp. Date       
Billing: 
Card/Account Name Street Address
                  City State Zip Code       

By submitting this My LifeCard Plan® Health Care Document Set Data Questionnaire, I/We, identified as the person(s) whose name(s) has/have been entered above, hereby attest and confirm that I/We have read the Contract & Purchase Agreement and fully understand and agree with all the terms and conditions prescribed therein and that its execution - by virtue of the submitting of this transaction / by activating the "Submit/Process" button - is an acceptance by me/us of all of its mutually protective covenants, terms and conditions, and agree that said Contract/Agreement is lawfully binding upon all parties identified therein.